High TB Burden Countries Research Articles

HIV infection and multidrug resistant tuberculosis: a systematic review and meta-analysis

BackgroundMultidrug-resistant tuberculosis (MDR-TB) in HIV infected individuals is a serious threat to global efforts to combat tuberculosis. Inconsistent findings on the association between HIV infection and MDR-TB were present in many studies. We aimed to review existing data on the relationship between HIV infection and MDR-TB systematically to assess the contribution of HIV on MDR-TB worldwide. We also investigated the patterns of MDR-TB by age, country-wise income, study designs, and global regions.MethodsWe utilized PubMed, Google Scholar, and ScienceDirect databases to select eligible studies for meta-analysis that were published between January 1, 2010, and July 30, 2020. The random-effects model was used to obtain the pooled odds ratio of the crude association between HIV and MDR-TB with a 95% confidence interval. We investigated the potential publication-bias by checking funnel plot asymmetry and using the Egger’s test. Moreover, we assessed the heterogeneity using the I2 statistic. Sensitivity analysis was performed based on sample size and adjustment factors. The protocol was registered with PROSPERO-CRD42019132752.ResultsWe identified 1603 studies through a database search, and after subsequent eliminations we selected 54 studies including 430,534 TB patients. The pooled odds of MDR-TB was 1.42 times higher in HIV-positive patients than HIV-negative patients (OR=1.42,CI=1.17–1.71, I2=75.8%). Subgroup analysis revealed that the estimated pooled odds for South-East Asian countries was 1.86, which is the highest in WHO regions (OR=1.86,CI=1.30–2.67, I2=0.00%), followed by Europe and Africa. The effect estimate was found to be higher for primary MDR-TB (OR=2.76,CI=1.70–4.46, I2=0.00%). There was also a trend towards increased odds of MDR-TB for HIV patients older than 40 years (OR=1.56,CI=1.17–2.06). The association was found to be significant in high-burden TB countries (OR=1.75, CI=1.39–2.19) and in high-income countries (OR=1.55, CI=1.06–2.27).ConclusionSuch findings indicate that HIV infection raises the risk of MDR-TB, and after contrasting it with the results of the earlier pooled study, it appeared to be an upward risk trend. Moreover, we found that the risk is the highest in the South-East Asian region. A balanced allocation of resources is needed to halt both primary and secondary MDR-TB, particularly in HIV infected people with 40 years of age and older.

A new resource on artificial intelligence powered computer automated detection software products for tuberculosis programmes and implementers

Recently, the number of artificial intelligence powered computer-aided detection (CAD) products that detect tuberculosis (TB)-related abnormalities from chest X-rays (CXR) available on the market has increased. Although CXR is a relatively effective and inexpensive method for TB screening and triaging, a shortage of skilled radiologists in many high TB-burden countries limits its use. CAD technology offers a solution to this problem. Before adopting a CAD product, TB programmes need to consider not only the diagnostic accuracy but also implementation-relevant features including operational characteristics, deployment mechanism, input and machine compatibility, output format, options for integration into the legacy system, costs, data sharing and privacy aspects, and certification. A landscaping analysis was conducted to collect this information among CAD developers known to have or soon to have a TB product. The responses were reviewed and finalized with the developers, and are published on an open-access website: www.ai4hlth.org. CAD products are constantly being improved and the site will continuously be updated to account for updates and new products. This unique online resource aims to inform the TB community about available CAD tools, their features and set-up procedures, to enable TB programmes to identify the most suitable product to incorporate in interventions.

Health and Social Factors Associated with Adverse Treatment Outcomes Among People with Multidrug-Resistant Tuberculosis in Sierra Leone: A National, Retrospective Cohort Study

Background: Multidrug-resistant Tuberculosis (MDR-TB) is a global health emergency. In Sierra Leone, a high TB burden country, we evaluated health and social factors associated with adverse MDR-TB treatment outcomes. Methods: This national, retrospective cohort study recruited all people notified with MDR-TB to the Sierra Leone National TB Program between April 2017 and September 2019, and with follow up to May 2021. MDR-TB was defined programmatically as rifampicin or rifampicin/isoniazid resistance. Treatment was with the 2017 WHO-recommended short (9–11 month) or long (18-24 month) regimens, both of which contained injectable aminoglycosides. An imputed multivariable logistic regression model examined associations of programmatic sociodemographic and clinical data with WHO-defined adverse treatment outcomes (death, treatment failure, loss-to-follow-up). A supplementary unimputed logistic regression model examined the association of direct susceptibility testing (DST) results with adverse outcome. Findings: Of notified MDR-TB cases, 365/370 (99%) were eligible to participate. Median age was 35 years (interquartile range 26-45), 263/365 (72%) were male, 71/365 (19%) HIV-positive, and 127/365 (35%) severely underweight (body mass index <16.5 units). DST was available for 315/365 (86%) participants. Treatment was started by 341/365 (93%), 317/341 (93%) and 24/341 (7%) with the short vs long regimen respectively. Overall, 267/365 (73%) had treatment success, of whom 254/317 (80%) and 13/24 (54%) were on the short vs long regimen; 95/365 (26%) had an adverse outcome, and 3/365 (1%) were still on treatment. Age 45-64 years (adjusted odds ratio [aOR]=2.3, 95%CI=1.1-4.8), untreated HIV (aOR=11, 95%CI=2.7-43), severe underweight (aOR=4.4, 95%CI=2.0-9.4), chronic renal failure (aOR=4.0, 95%CI=1.1-16), chronic lung disease (aOR=2.2, 95%CI=1.1-4.4), and long regimen (aOR=7.6, 95%CI=2.7-21) were associated with adverse outcome. Being HIV positive and on antiretroviral therapy was not associated with adverse outcome (aOR=0.93, 95%CI=0.37-2.4). Of people with MDR-TB and untreated HIV, 14/20 (70%) died, 8/14 (57%) of whom received no treatment. The supplementary unimputed regression model showed that, after adjusting for regimen received, prothionamide resistance was associated with adverse outcome (aOR=2.9, 95%CI=1.3-6.3). Interpretation: MDR-TB treatment success rates in Sierra Leone approached WHO targets (73% vs ≥75%). The short regimen was associated with higher success rates. Adverse outcome rates among working-age people and those with severe underweight, untreated HIV, chronic lung disease, and renal failure, suggest a role for integrated TB, HIV, and non-communicable disease services alongside nutritional and socioeconomic support for people with MDR-TB in Sierra Leone. The association of prothionamide resistance with adverse outcome appears to support the WHO conditional recommendation to consider alternative regimens in such cases or in areas with high prevalence of prothionamide resistance. Funding: Wellcome Trust (209075/Z/17/Z), Joint Global Health Trials (MR/V004832/1) Declaration of Interest: None to declare. Ethical Approval: Ethical approval was obtained from the Ethics Review and Scientific Committee of the Ministry of Health and Sanitation, Government of Sierra Leone.

Treatment Outcomes and Predictors of Outcome in Multidrug Resistance Tuberculosis (MDR-TB) Cohort of Patients in Addis Ababa, Ethiopia

Multidrug Resistance Tuberculosis (MDR-TB) is a major global public health crisis that needs great emphasis. Ethiopia is one of the 30 high TB, TB/HIV and drug resistant TB (DR-TB) burden countries globally and stands third among African countries. Treatment outcomes of MDR-TB are one of the essential performance indicators in evaluating the national TB control program. Such assessments however are limited at the facility and program level in Ethiopia. This study reported treatment outcomes and outcome predictors from a cohort of MDR-TB patients who were on WHO's longer treatment regimen at ALERT Hospital in Addis Ababa, Ethiopia. A retrospective assessment of patients’ records was made and data were collected for the period 2011-to 2016 using structured checklist. Data were double entered to Red Cap and exported to SPSS v20 for analysis. Descriptive statistics was computed to get summary results, bivariate and multivariate analysis was used to identify factors which affect the dependent variables. Therefore a total of 363 (53.7% males and 46.3% females) MDR-TB patients were included in the study. The mean age of the study participants was 29.6 years with the standard deviation of 11.2 years; the mean BMI was 18.5 with standard deviation of 3.0; and 78 (21.5%) were HIV positive. The most prevalent side effects were gastric disturbance which includes epigastric pain/discomfort, indigestion, bloating and nausea/vomiting (46.25%). Electrolyte abnormality occurred in (39.53%) of the patents. Among all assessed patients, 147 (40.5%) were cured, 132 (36.4%) completed their treatment, treatment failure occurred in three patients (0.8%), 46 (12.7%) patients died and 35 (9.6%) patients were lost to their follow-up. Overall, treatment success of 279 (76.9%) was observed in this cohort. Female and employed patients who can generate regular income had favorable treatment outcome with (AOR: 2.5; 95%CI: 1.4, 4.2), (AOR: 2.4; 95%CI: 1.4, 4.0) respectively Patients with HIV were 50% lower to have a favorable treatment outcome than HIV negative patients with (AOR: 0.5; 95%CI: 0.3, 0.9). So, it has been concluded that treatment success rate was generally encouraging. However, significant numbers of patients were lost to follow up and died. Thus, targeted interventions towards addressing factors that affected treatment outcome in MDR-TB patient management should be made. Strengthened follow up should also be in place to reduce number of lost to follow up and deaths in MDR-TB patients.

A CASE REPORT OF TUBERCULAR TRANSVERSE MYELIT

INTRODUCTION Transverse myelitis (TM) is a focal inflammatory disorder of the spinal cord, often associated with infectious disease, which can lead to permanent paraplegia or quadriplegia. CASE REPORT: A 56-year-female ,presentedwithb/l lower limb weakness since 2 days,b/l lower limb loss of sensations since two days,inability to walk since one day,and urinary retention requiring catherisation and fecal incontinence since one day. By history there was also , intermittent fever and night sweats. There was past history of respiratory tract infection two weeks back which partially subsided with antibiotics.Patient is known hypertensive and hypotyroid. Vitals:-normal General physical examination showed moderate general condition, and presence of crackles in both lungs. Neurological examination :- arreflecticlowerlimbs,paraplegia inboth lower limbs (strength 0/5 according to the Medical Research Council grade), and a positive Babinski sign,loss of all sensations completely below umbilicus. CONCLUSION- Tuberculous transversal myelitis is rare but should be consid- ered in the differential diagnosis of non-compressive myelopa- thies, in high burden TB countries or in the presence of clinical symptoms suggestiveofTB

Screening diabetes mellitus patients for pulmonary tuberculosis: a multisite study in Indonesia, Peru, Romania and South Africa.

Diabetes mellitus (DM) patients are three times more likely to develop tuberculosis (TB) than the general population. Active TB screening in people with DM is part of a bidirectional approach. The aim of this study was to conduct pragmatic active TB screening among DM patients in four countries to inform policy. DM patients were recruited in Indonesia (n=809), Peru (n=600), Romania (n=603) and South Africa (n=51). TB cases were diagnosed using an algorithm including clinical symptoms and chest X-ray. Presumptive TB patients were examined with sputum smear and culture. A total of 171 (8.3%) individuals reported ever having had TB (South Africa, 26%; Indonesia, 12%; Peru, 7%; Romania, 4%), 15 of whom were already on TB treatment. Overall, 14 (0.73% [95% confidence interval 0.40 to 1.23]) TB cases were identified from screening. Poor glucose control, smoking, lower body mass index, education and socio-economic status were associated with newly diagnosed/current TB. Thirteen of the 14 TB cases diagnosed from this screening would have been found using a symptom-based approach. These data support the World Health Organization recommendation for routine symptom-based screening for TB in known DM patients in high TB-burden countries. DM patients with any symptoms consistent with TB should be investigated and diagnostic tools should be easily accessible.

In the Shadows of the COVID-19 Pandemic

In the Shadows of the COVID-19 Pandemic

Tuberculosis, human rights, and law reform: Addressing the lack of progress in the global tuberculosis response.

Mathew Kavanagh and co-authors discuss law reform in the global tuberculosis response.

Prevalence of Antibiotic-Resistant Pulmonary Tuberculosis in Bangladesh: A Systematic Review and Meta-Analysis.

Resistance to anti-tuberculosis (anti-TB) antibiotics is a major public health concern for many high-TB burden countries in Asia, including Bangladesh. Therefore, to represent the overall drug-resistance pattern against TB in Bangladesh, a systematic review and meta-analysis was conducted. Databases such as PubMed, Scopus, and Google Scholar were searched to identify studies related to antibiotic-resistant TB. A total of 24 studies covering 13,336 patients with TB were secured and included. The random-effects model was used to calculate the summary estimates. The pooled prevalence of any, mono, multi, poly, and extensive anti-TB antibiotic-resistances were 45.3% [95% CI: 33.5–57.1], 14.3% [95% CI: 11.4–17.2], 22.2% [95% CI: 18.8–25.7], 7.7% [95% CI: 5.6–9.7], and 0.3% [95% CI: 0.0–1.0], respectively. Among any first and second-line anti-TB drugs, isoniazid (35.0%) and cycloserine (44.6%) resistances were the highest, followed by ethambutol (16.2%) and gatifloxacin (0.2%). Any, multi, and poly drug-resistances were higher in retreatment cases compared to the newly diagnosed cases, although mono drug-resistance tended to be higher in newly diagnosed cases (15.7%) than that in retreatment cases (12.5%). The majority (82.6%) of the included studies were of high quality, with most not exhibiting publication bias. Sensitivity analyses confirmed that all outcomes are robust and reliable. It is concluded that resistance to anti-TB drugs in Bangladesh is rampant and fast growing. Therefore, the implementation of a nationwide surveillance system to detect suspected and drug-resistant TB cases, as well as to ensure a more encompassing treatment management by national TB control program, is highly recommended.

Molecular epidemiology of clinical Mycobacterium tuberculosis complex isolates in South Omo, Southern Ethiopia

BackgroundTuberculosis (TB) is caused by Mycobacterium tuberculosis complex (MTBC). Mapping the genetic diversity of MTBC in high TB burden country like Ethiopia is important to understand principles of the disease transmission and to strengthen the regional TB control program. The aim of this study was to investigate the genetic diversity of Mycobacterium tuberculosis complex (MTBC) isolates circulating in the South Omo, southern Ethiopia.MethodsMTBC isolates (N = 156) were genetically analyzed using spacer oligotyping (spoligotyping) and mycobacterial interspersed repetitive unit-variable number of tandem repeat (MIRU-VNTR) typing. Major lineages and lineages were identified using MTBC databases. Logistic regression was used to correlate patient characteristics with strain clustering.ResultsThe study identified Euro-American (EA), East-African-Indian (EAI), Indo-Oceanic (IO), Lineage_7/Aethiops vertus, Mycobacterium bovis and Mycobacterium africanum major lineages in proportions of 67.3% (105/156), 22.4% (35/156), 6.4% (10/156), 1.9% (3/156), 1.3% (2/156) and 0.6% (1/156), respectively. Lineages identified were Delhi/CAS 23.9% (37/155), Ethiopia_2 20.6% (32/155), Haarlem 14.2% (22/155), URAL 14.2%(22/155), Ethiopia_3 8.4% (13/155), TUR 6.5% (10/155), Lineage_7/Aethiops vertus 1.9% (3/155), Bovis 1.3% (2/155), LAM 1.3% (2/155), EAI 0.6% (1/155), X 0.6% (1/155) and Ethiopia H37Rv-like strain 0.6% (1/155). Of the genotyped isolates 5.8% (9/155) remained unassigned. The recent transmission index (RTI) was 3.9%. Orphan strains compared to shared types (AOR: 0.09, 95% CI: 0.04–0.25) were associated with reduced odds of clustering. The dominant TB lineage in pastoral areas was EAI and in non-pastoral areas was EA.ConclusionThe epidemiological data, highly diverse MTBC strains and a low RTI in South Omo, provide information contributing to the TB Control Program of the country.

Tuberculosis control programme from NTCP to RNTCP to NTEP

India, the highest TB burden country in the world, is having an estimated incidence of 26.9 lakh cases in 2019 (WHO). The year 2019 marks another milestone year for TB surveillance effort in India, with a record high notification of 24 lakhs cases; an increase of over 12% as compared to 2018. Of the 24 lakhs TB cases,(1) 21.6 lakhs were incident TB cases (New and Relapse/ Recurrent). This amount to an incident notification rate of approximately 159 cases/lakh against the estimated incidence rate of 199 cases/ lakh population; thus, closing the gap between the estimated and notified incident cases to just 40 Cases per lakh population, or an approximate of 5.4 lakh missing cases across India.

Trends in socioeconomic inequalities in childhood BCG immunization coverage in Pakistan

Abstract Background Although, WHO notes that there has been 'tremendous progress' towards controlling spread of Tuberculosis (TB) by 2015, situation in endemic countries like Pakistan need global attention. Pakistan currently ranks fifth among TB-high burden countries and it accounts for 61% of the TB burden in the WHO Eastern Mediterranean Region. We aim to explore the trends in relative and absolute socioeconomic inequalities in BCG vaccination coverage. Methods Data from Pakistan Demographic and Health Surveys (PDHS) 2006-7 (n = 9177 data used 8442), and 20012-13 (n = 13558, used n = 6982) were used. Information was collected from all mothers in reproductive age group, regarding BCG vaccination of their children aged &amp;lt; 5 years. Wealth index and education were used to assess socioeconomic position. Socioeconomic inequalities for BCG vaccination coverage were assessed by calculating Relative Index of Inequality (RII) and Absolute Index of Inequality (SII). Results Although reported frequency of not getting the child BCG vaccinated has decreased over the decade (25% in 2006, 18% in 2013). Nevertheless, socioeconomic inequalities in BCG vaccination have significantly widened over the last decade. Education related inequalities [2006-7 Urban: SII=-1.34 (-0.91, -1.76); 2012-13 Urban: SII=-1.88 (-1.43, -2.32)]; [2006-7 Rural: SII=-1.31 (-0.96, -1.65); 2012-13 Rural: SII=-1.54 (-1.13, -1.94)] have increased. Similarly, wealth related inequalities [2006-7 Urban: SII=-1.27 (-0.91, -1.62); 2012-13 Urban: SII=-1.75 (-1.37, -2.12)]; [2006-7 Rural: SII=-1.19 (-0.98, -1.39); 2012-13 Rural: SII=-1.72 (-1.43, -2.00)] have increased. Conclusions Widening absolute inequalities in BCG vaccination coverage among children over the last decade in a TB-high burden country gives rise to global concern, at a time when world aims for tuberculosis free future. The results warrant the essential public health efforts to avoid further widening in TB related socioeconomic inequalities in Pakistan. Key messages The results warrant the need to continue monitoring of TB control at population level. Study findings may help to improved TB management programs to initiate evidence-based guidelines for maternal and child health.

8.H. Workshop: People-centered approach in TB treatment. Experience from Eastern European countries

Abstract Objectives The current global “END TB” strategy emphasizes the importance of people-centered approach in TB treatment. The latter gives patients a central role in the course of treatment, prioritizing social circumstances, needs, and values of patients. Some high burden TB countries in the European region have integrated different models of people-centered TB treatment in their national TB control programs, while others are working towards adopting and introducing relevant models for their settings. The objectives of the workshop are: To bring together existing evidence and experience of countries that are in different stages in terms of implementing people-centered approach in TB care.To contribute to the integration of evidence-based practices, including people-centered approach, in different settings and countries.To promote regional cooperation through information exchange, networking and discussion. The session will include experts, researchers and public health practitioners from Armenia and Ukraine. The proposed workshop will follow the regular format with five presentations, each of them dedicated to a country-specific experience in people-centered approach in TB treatment. The presenters will provide examples about different components of people-centered approach implementation in different settings. The discussion session with workshop presenters and attendees will facilitate further conversation about lessons learned from recent successes/failures in each country. This will provide practical advice and recommendations regarding development and implementation of best practices of people-centered approach in TB care. Key messages The workshop will advance the understanding about successes, challenges, and lessons learned from implementation of people–centered approach in TB treatment in different settings. The workshop will facilitate discussion and information exchange among participants, helping public health practitioners to adapt people–centered approach in TB treatment in their countries.

A case control study for factors of Multidrug Resistant Tuberculosis in East Sikkim, India

Abstract Background Tuberculosis (TB) remains a major public health problem in the developing world and India is the highest TB burden country in the world in terms of absolute number of incident cases that occur each year. The emergence of Multidrug Resistant Tuberculosis (MDR TB) is posing threat to global efforts of TB control. The hilly state of Sikkim has the highest proportion of MDR TB cases in India. Hence there is an emerging need to identify the factors for the rapid rise of MDR TB in Sikkim. Methods All the MDR TB cases registered under Revised National TB Control Programme in East district of Sikkim in the first &amp; second quarter of 2019 was compared with double the number of matched controls taken from the same geographical area and ethnicity but not from the same family members. Results A total of 78 cases and 156 controls were studied. The mean age of the study participants was 43 years (SD ± 14 years). The most statistically significant risk factors were as follows: overcrowding (OR 2.68); household air pollution (OR 2.55); inadequate ventilation (OR 2.05); previous history of tuberculosis (OR 4.03) with history of relapse/failure; known contact of MDR tuberculosis (OR 4.01); having diabetes (OR 3.96); smoking (OR 3.96) Conclusions This study shows that clinical and demographic features can be used to indicate higher risks of drug resistance in this setting. Information was obtained on why Sikkim being a small State with very less population and a good per capita expenditure in health has the highest proportion of MDR-TB in India. Key messages Sikkim is the smallest state in India with the highest proportion of MDR TB. Previous history of TB with history of relapse/failure, contact of MDR TB emerged as the most significant risk factors.

Prevalence, risk factors and treatment outcomes of isoniazid resistant TB in Bulawayo city, Zimbabwe: A cohort study

Introduction:The isoniazid-resistant TB poses a threat to TB control efforts. Zimbabwe, one of the high TB burden countries, has not explored the burden of isoniazid resistant TB. Hence among all bacteriologically-confirmed TB patients diagnosed in Bulawayo City during March 2017 and December 2018, we aimed to assess the proportion with isoniazid resistant TB and associated factors. Also, we aimed to describe the TB treatment outcomes.Methodology:A cohort study involving routinely collected data by the National TB Reference Laboratory (NTBRL) in Bulawayo City and National TB programme of Zimbabwe. The percentage with 95% confidence interval (CI) was used to express the proportion with isoniazid-resistant TB. The modified Poisson regression was used to assess the association of demographic and clinical characteristics with isoniazid mono-resistant TB.Results:Of 2160 bacteriologically-confirmed TB patients, 1612 (74.6%) had their sputum received at the NTBRL and 743 (46.1%) had culture growth. Among those with culture growth, 34 (4.6%, 95% CI: 3.5–6.7) had isoniazid mono-resistant TB, 25 (3.3%, 95% CI: 2.2–4.9) had MDR-TB. Thus, 59 (7.9%, 95% CI: 6.1–10.1) had isoniazid-resistant TB. Children < 15 years had a higher prevalence of isoniazid mono-resistant TB (aPR= 3.93; 95% CI: 1.24–12.45). Among those with rifampicin sensitive TB, patients with isoniazid-sensitive TB had higher favourable treatment outcomes compared to those with isoniazid-resistant TB (86.3% versus 75.5%, p = 0.039).Conclusions:The prevalence of isoniazid-resistant TB was low compared to neighbouring countries with high burden of TB-HIV. However, Zimbabwe should consider reviewing treatment guidelines for isoniazid mono-resistant TB due to the observed poor treatment outcomes.

Is International Travel an Emerging Issue on Transmission of Beijing Lineage Mycobacterium tuberculosis?

Mycobacterium tuberculosis belonging to Beijing sublineage (BL) is associated with high tuberculosis (TB) transmission, multidrug resistance, and adverse treatment outcomes. Sri Lanka experiences an increase in the number of travellers/workers to and from high TB-burden countries, and there is risk of getting BL strains imported into the country. In this context, a cohort study was conducted to assess the prevalence of BL strains among pulmonary tuberculosis (PTB) patients in the Kandy district of Sri Lanka (a popular tourist destination) and its association with patients' sociodemographic and clinical characteristics. The study population included sputum smear-positive PTB patients diagnosed from February 2018–July 2019. Fresh sputum samples were collected for culturing and conducted polymerase chain reaction using BL-specific primers. Among the 101 patients recruited, presence of BL strains could be ascertained in 94 patients of which 24 (26%; 95% CI: 18%–35%) had BL strains. Prevalence of BL strains was higher among those with high sputum smear grades (2+ and 3+) (P < 0.05) and those who had travelled abroad (P < 0.05). The prevalence was also higher among young people (aged <35 years). Treatment success rates were similar in patients with (83%) and without BL strains (83% vs. 81%; P value = 0.8375). The prevalence of BL strains in Kandy, Sri Lanka, was high compared to previously reported figures in Sri Lanka, and the percentage drives closer to the countries in South East Asia. International travel raises itself as an emerging issue in BL transmission urging the need of policies and practices in immigration/emigration strategies. The study findings have the potential to alter the TB epidemiology in the country and might represent the situation in other underexplored countries as well. Therefore, it is important to monitor the trends and factors related to the prevalence of Beijing strains globally and make decisions as a whole.

Smoking prevalence among tuberculosis patients: A crosssectional study in Bangladesh and Pakistan.

INTRODUCTIONSmoking has a negative impact on TB outcomes. We estimated the proportion of TB patients who smoke and are willing to quit in two high TB burden countries, Bangladesh and Pakistan.METHODSA cross-sectional survey was conducted among TB patients to assess their eligibility and recruit them to a smoking cessation randomized controlled trial. Adults diagnosed with TB were recruited from 32 health facilities in Bangladesh and Pakistan. Data on smoking behaviour and willingness to quit were collected and analysed.RESULTSIn total, 13934 TB patients completed the survey between June 2017 and April 2018. The prevalence of smoking in these TB patients was estimated to be 22.5% (95% CI: 21.8, 23.2). Moreover, the prevalence of smoking in TB patient population was 8% (RR=1.49; 95% CI: 7.1–8.9; p<0.01) and 8.3% (RR=1.24; 95% CI: 7.3–9.4; p<0.01) higher than smoking prevalence in the general population in Bangladesh and Pakistan, respectively. Among TB patients who smoke, 97.7% (95% CI: 97.2–98.2) were willing to quit.CONCLUSIONSThe estimated prevalence of smoking was higher in TB patients than the general population; however, a vast majority of TB patients who smoke were willing to quit.

An observational report of universal GeneXpert testing of inpatients with diagnosed or presumptive TB in the Philippines.

BackgroundThe Philippines is a high TB and multidrug-resistant TB burden country. Although the scale-up of GeneXpert testing is occurring, the benefits of universal Xpert-Mycobacterium tuberculosis/ rifampicin (MTB/RIF) testing in inpatients have not been documented.MethodsRoutine GeneXpert testing irrespective of priority criteria for testing was conducted within a prospective cohort of all adults with known or presumptive TB admitted to a tertiary infectious diseases hospital in Manila. Study-specific TB diagnosis was decided upon bacteriological results, chest x-ray assessment, if already on anti-TB treatment (ATT) at admission and a cough duration of ≥2 wk.ResultsOf submitted sputum samples, 87.1% (277/318) had valid acid-fast bacilli (AFB) microscopy and Xpert® MTB/RIF results. Xpert® MTB/RIF was positive in 97.7% (n = 87/89) of AFB-positive patients and 25.5% (n = 48/188) of AFB-negative patients. Bacteriological confirmation in smear negative cases not on ATT prior to admission was 25.2% (34/135). Rifampicin resistance was detected in 26/135 Xpert positive cases (19.3%), including nine who might not otherwise have been detected, representing a 53% increase in yield.ConclusionUniversal GeneXpert testing in this setting enhanced the yield of bacterial confirmation, revealing a high incidence of rifampicin resistance and suggesting a need for further investigations in Xpert-negative/smear-positive patients who may not have mycobacterial TB.

A comparative impact evaluation of two human resource models for community-based active tuberculosis case finding in Ho Chi Minh City, Viet Nam

BackgroundTo achieve the WHO End TB Strategy targets, it is necessary to detect and treat more people with active TB early. Scale–up of active case finding (ACF) may be one strategy to achieve that goal. Given human resource constraints in the health systems of most high TB burden countries, volunteer community health workers (CHW) have been widely used to economically scale up TB ACF. However, more evidence is needed on the most cost-effective compensation models for these CHWs and their potential impact on case finding to inform optimal scale-up policies.MethodsWe conducted a two-year, controlled intervention study in 12 districts of Ho Chi Minh City, Viet Nam. We engaged CHWs as salaried employees (3 districts) or incentivized volunteers (3 districts) to conduct ACF among contacts of people with TB and urban priority groups. Eligible persons were asked to attend health services for radiographic screening and rapid molecular diagnosis or smear microscopy. Individuals diagnosed with TB were linked to appropriate care. Six districts providing routine NTP care served as control area. We evaluated additional cases notified and conducted comparative interrupted time series (ITS) analyses to assess the impact of ACF by human resource model on TB case notifications.ResultsWe verbally screened 321,020 persons in the community, of whom 70,439 were eligible for testing and 1138 of them started TB treatment. ACF activities resulted in a + 15.9% [95% CI: + 15.0%, + 16.7%] rise in All Forms TB notifications in the intervention areas compared to control areas. The ITS analyses detected significant positive post-intervention trend differences in All Forms TB notification rates between the intervention and control areas (p = 0.001), as well as between the employee and volunteer human resource models (p = 0.021).ConclusionsBoth salaried and volunteer CHW human resource models demonstrated additionality in case notifications compared to routine case finding by the government TB program. The salaried employee CHW model achieved a greater impact on notifications and should be prioritized for scale-up, given sufficient resources.

Declining Trends in Childhood TB Notifications and Profile of Notified Patients in the City of Harare, Zimbabwe, from 2009 to 2018.

Globally, childhood tuberculosis (TB among those aged <15 years) is a neglected component of national TB programmes in high TB burden countries. Zimbabwe, a country in southern Africa, is a high burden country for TB, TB-HIV, and drug-resistant TB. In this study, we assessed trends in annual childhood TB notifications in Harare (the capital of Zimbabwe) from 2009 to 2018 and the demographic, clinical profiles, and treatment outcomes of childhood TB patients notified from 2015–2017 by reviewing the national TB programme records and reports. Overall, there was a decline in the total number of TB patients (all ages) from 5,943 in 2009 to 2,831 in 2018. However, the number of childhood TB patients had declined exponentially 6-fold from 583 patients (117 per 100,000 children) in 2009 to 107 patients (18 per 100,000 children) in 2018. Of the 615 childhood TB patients notified between 2015 and 2017, 556 (89%) patient records were available. There were 53% males, 61% were aged <5 years, 92% were new TB patients, 85% had pulmonary TB, and 89% were treated for-drug sensitive TB, 3% for drug-resistant TB, and 40% were HIV positive (of whom 59% were on ART). Although 58% had successful treatment outcomes, the treatment outcomes of 40% were unknown (not recorded or not evaluated), indicating severe gaps in TB care. The disproportionate decline in childhood TB notifications could be due to the reduction in the TB burden among HIV positive individuals from the scale up of antiretroviral therapy and isoniazid preventive therapy. However, the country is experiencing economic challenges which could also contribute to the disproportionate decline in childhood TB notification and gaps in quality of care. There is an urgent need to understand the reasons for the declining trends and the gaps in care.